Painful Product Conversions

Partnering with Nursing for Positive Results

August 15, 2016 | Content Areas: Value Analysis | Tags: Clinical Resource Management, Lean/Six Sigma | Formats: White Paper
Authors: Susan A. Wills, MBA, CMRP, FAHRMM

Download the Fellow Paper to view corresponding tables and graphs.

Susan A. Wills, MBA, CMRP, FAHRMM
Director Strategic Sourcing and Contracts
Dana Farber Cancer Institute
Brookline, MA

Abstract

This paper describes the development of a multidisciplinary and innovative product conversion process at the Dana-Farber Cancer Institute (DFCI) in Boston, Massachusetts, when the existing process for changing products was dysfunctional. Indeed, effective change management is critical to achieving successful outcomes. The paper will explore some of the reasons why change fails; including lack of healthy working relationships, failure to communicate effectively, lack of leadership, lack of commitment, and inadequate planning. By examining the background of DFCI, and its products and standards team in particular, this paper investigates the reasons why the current process of changing products was failing.  The writer will take a particularly close look at the relationship between nursing and the supply chain. The included case studies review actual conversions—one before implementation of a new product conversion process and one after. The latter case study describes the tools and processes that helped make the product conversion successful, among them Lean tools to help map out original and current states and identify problem points. The resulting product conversion process is easy to follow and equally easy to implement. This paper is presented as a way of sharing a process and tool that are customizable for any organization.

Introduction
Product conversions are common in health care supply chains—so shouldn’t they be easy by now? Yet after two failed product conversions since we rejuvenated our products and standards team at the Dana-Farber Cancer Institute, we began to seriously wonder. These conversions were a painful initiation—certainly an experience that we didn’t want to repeat—so we made it our mission to try to improve the process.

“Translational medicine,” or turning research discoveries into real clinical applications, is the hallmark practice of DFCI. Dr. Sydney Farber used this approach when he founded the institute in the 1940s. As former DFCI president Dr. David Nathan (2014) once observed, “[Dr. Farber’s] dream was that on one of the upper floors, a scientist would yell, ‘Aha!’ and rush down and give a child medicine that would cure him or her.” Indeed, the discoveries now made in DFCI labs spark discussion of potential therapeutic uses. DFCI staff members test the promising therapy, fine-tuning it and retesting in DFCI’s labs before proceeding to clinical trials. Patients and clinicians provide valuable feedback—not only on efficacy but also on the best approach for delivering care during treatment. DFCI’s “bench to bedside” philosophy is still at the center of the work that DFCI staff members do today—for DFCI trains new generations of physicians and scientists to advance the understanding, prevention, and treatment of cancer and cancer-related diseases.

However, DFCI is made up of complex inpatient and outpatient centers at a variety of locations, and this can make product conversions challenging. Although product standardization is one of DFCI’s goals, it is not always possible. Regardless, DFCI focuses on providing optimal patient care through evidence-based product application.

Oncology nursing at DFCI is highly specialized and complex, aligning leadership with disease centers. Many layers of nursing interact with the supply chain—nursing directors, clinical nurse coordinators (charge nurses), and clinical nurse specialists (educators), all in what are considered leadership roles. Another critical role reporting to nursing is that of the clinic assistants, who manage supplies and place non-inventory supply orders.

Criteria for Successful Change Management
To be successful, the product conversion process requires effective change management skills. Some critical elements include the development of healthy working relationships, effective communication skills, strategic planning, and strong leadership. Yet these critical elements have been missing from our product conversion process—we must embrace them or else continue to fail. Indeed, effective change management is critical to successful outcomes, according to Prosci:

Change management is the discipline that guides how we prepare, equip and support individuals to successfully adopt change in order to drive organizational success and outcomes.

While all changes are unique and all individuals are unique, decades of research show there are actions we can take to influence people in their individual transitions. Change management provides a structured approach for supporting the individuals in your organization to move from their own current states to their own future states.

DFCI is not a traditional hospital. Its many disease centers use many distinct products. Accordingly, implementing standards or a formulary was difficult. Nor did we have a standardized process for changing products. Not surprisingly, even the simplest of product changes was challenging—if something could go wrong, it did.

DFCI has had a traditional products and standards team for many years, but the team met only sporadically, and it drove very few strategic initiatives. Those product changes that were made were not well planned, nor were they well communicated. Leadership, interest, and engagement were all lacking. The relationship between nursing and supply chain was neither strong nor trusting. Regrettably, such unhealthy relationships are not uncommon in hospitals today.

For nursing and supply chain staff members to work together, they must first understand each other’s roles, says Chris O’Connor, Executive Vice President of GYNHA Ventures, Inc. in an article written for Hospital Newspaper-NJ in May 2012:

Materials managers can become too narrowly focused on price and the procurement process. The supply chain has to go beyond budget line-items and better understand how patient care issues more broadly impact costs.

A successful clinical-materials relationship depends on the ability of nurses to explain the patient care impacts that are related to supplies and the supply chain as well as to articulate how new or different products can impact overall costs.

Thus we needed a balance between clinical excellence and cost-consciousness. Many provider- or clinic-specific products were requested without knowledge or consideration of what else was available—or of the cost. In such a situation, the products and standards team became invaluable, giving us a forum for having discussions about these issues. Today’s iteration is a typical multidisciplinary team, meeting monthly and actively identifying product standardization and utilization opportunities. Supply chain personnel also focused on reengaging nursing personnel by holding monthly meetings whose agendas were valuable for all participants. What’s more, supply chain staff members proactively brought cost saving and supply utilization initiatives and opportunities to the meetings, responding positively to our detailed cost analyses and our hands-on approach to evaluating new products. After about 12 months in this increasingly productive and enjoyable environment, our team had grown—in focus as well as numbers.

Although we had begun to thoughtfully choose products, we found that actually implementing a new product or a product change was ineffective. Although we had the best of intentions, we were not working collaboratively. Each of us was assigned a role in the conversion, but we weren’t communicating effectively during the process.

Case Study 1: Chemotherapy Gowns
The first product conversion after my arrival at DFCI was disastrous. Purely by chance, we discovered that the chemotherapy gowns that the facility had been using for years were not impervious and thus risked exposing members of staff to hazardous drugs. Naturally, the environmental, health, and safety officer requested immediate conversion to an approved product that met testing requirements—and so our team members felt enormous pressure to move forward quickly. Under pressure, we cut corners, deciding not to put the newly selected gown through trials beforehand. We also failed to communicate effectively with both the distributor, who didn’t stock the gown we selected, and the clinical staff, who received notification about the conversion before the gowns had even arrived on our loading dock.

However, because we had some experience with Lean methodologies and tools, we wanted to use process mapping to map out our original product conversion process and to identify the strengths and weaknesses of our original process, deciding where we wanted to be with our next conversion.

Lean Methodology/Process Mapping
Consider the approach of the Lean Enterprise Institute (“What is Lean?” n.d.):

A lean organization understands customer value and focuses its key processes to continuously increase it. The ultimate goal is to provide perfect value to the customer through a perfect value creation process that has zero waste. To accomplish this, lean thinking changes the focus of management from optimizing separate technologies, assets, and vertical departments to optimizing the flow of products and services through entire value streams that flow horizontally across technologies, assets, and departments to customers.

Eliminating waste along entire value streams, instead of at isolated points, creates processes that need less human effort, less space, less capital, and less time to make products and services at far less costs and with much fewer defects, compared with traditional business systems. Companies are able to respond to changing customer desires with high variety, high quality, low cost, and with very fast throughput times. Also, information management becomes much simpler and more accurate.

According to the Six Sigma Study Guide (“Process mapping,” 2013),

Process mapping is the graphical representation with illustrative descriptions of how things get done. It helps the participants to visualize the details of the process closely and guides decision making. One can identify the major areas of strengths and weaknesses in the existing process, such that the contribution of individual steps in the process are recognized. Further, it helps to reduce the cycle times and defects in the process and enhances its productivity.

The major components of a process map include the inputs, outputs and the steps in the process. A good process map should illustrate the flow of the work and the interaction with the organization.

Our original state process map now seems very basic, but it depicts the steps we followed during our conversion process. 

Figure 1.1. The original process we followed for product conversions. [Download the PDF to view image].

After the product conversion was complete, we debriefed, using our process map as a starting point. Although it might look as if the process flowed, different people were managing each step—and it ended up being a disaster. What we were missing was the touchpoint between each process. Indeed, the nursing team members pointed out that the original product conversion process (Figure 1.1) was really a “pass-on” process, not a “handoff” process—and thus neither party was aware of what the other party was doing. Some assumed that certain major steps had been completed when in fact they had not.

Handoff communication was a 2006 National Patient Safety Goal—a game-changer in health care, for effective communication is the key to patient safety as caregivers change each shift or move between departments for testing. The National Center for Biotechnology Information (NCBI) defines handing off as follows:

The transfer of essential information and the responsibility for care of the patient from one health care provider to another is an integral component of communication in health care. This critical transfer point is known as a handoff. An effective handoff supports the transition of critical information and continuity of care and treatment. However, the literature continues to highlight the effects of ineffective handoffs: adverse events and patient safety risks. The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first.” (Friesen, White, & Byers, 2008)

Figure 1.2. Our original state process map, identifying what worked and what did not. [Download the PDF to view image].

We realized that we were missing an essential ingredient: the handoff. We had to ensure that each team member communicated with the next after completing his or her assigned task. But more than that was going wrong. During the debrief, we added notes to the process map, using “happy clouds” (puffy clouds) to call out what went right during the chemotherapy gown conversion and “storm clouds” (jagged clouds) to indicate what went wrong (Figure 1.2).

As is evident by the process map, we had no happy clouds to add. Nothing went right. The decision not to trial was a poor one—yet our team had decided that the danger posed by continuing to risk exposure far outweighed the benefits of a long, possibly drawn-out, trial. Added pressure came when we discovered that the members of clinical staff preferred the previous gown. The newly selected gown was heavier and thus hotter. To make things worse, the Oncology Nursing Society began recommending that disposable chemotherapy gowns be worn only once per patient—yet until then, clinical staff members had been able to wear the same gown until it was contaminated, even if that meant until the end of the day.

But nursing leadership wanted DFCI to comply with the new safe handling standard. With its implementation, the numbers of gowns used per day—and the issues involved in disposing of such quantities of gowns—became a significant issue. We failed to consider the effects of an influx of heavier gown on the waste stream. Moreover, the waste containers in which the chemotherapy gowns were disposed were not large enough to handle the increased volume. Because this conversion arose in response to a safety concern, we would be pulling the existing product rather than using it; accordingly, we had a large inventory of product left over, with no plans to return it or exchange it for credit.

Our more striking lesson came in discovering that a lack of effective communication and collaboration, even among team members, had played a significant role in our failure. Indeed, a failed product conversion can point to a failed and untrusting relationship between nursing and supply chain. Yet the supply chain provides a critical support system for nursing—nursing staff members cannot care for patients without supplies and support. What’s more, a failed product conversion can be costly to the supply chain when dedicated resources require reassignment to fix what went wrong. We might also incur additional costs expediting supplies. Thus the product conversion process is a crucial part of building and sustaining trust.

The Checklist
When I worked at Concord Hospital in Concord, New Hampshire, we encountered the same kinds of problems with product conversions: We just couldn’t seem to get all the pieces to fall into place when we needed them to. So our Clinical Quality Value Analysis (CQVA)™ leadership team developed a solution: a simple checklist.

A checklist, says reference.com (“What is the purpose of a checklist?” n.d.),

is a comprehensive list of crucial tasks to be completed in a specified order; this ensures no important step is forgotten. Checklists are used in several different fields, from complex medical surgeries to building inspections. The use of a checklist can help improve efficiency by minimizing mistakes. Checklists also provide a written trail detailing what was done at every step of a project. The ideal checklist should be precise, efficient, easy to use in any situation and straight to the point. All the items on a good checklist should be actionable and grouped by category.

When Captain Sully Sullenberger, the pilot who landed his plane in the Hudson River, spoke at a recent health care conference, he opened his presentation by recalling what was happening in the cockpit during those 208 seconds after his plane struck a flock of birds: “We didn’t have time to consult all the written guidance; we didn’t have time to complete the appropriate checklists.” Yes, airlines use checklists, too—and so do many other industries. If a checklist worked for them, then, we thought, it would work for product conversions, too. After the members of our products and standards team mulled over the checklist concept, everyone was willing to give it a try. Accordingly, we took the checklist developed by the CQVA™ leadership team at Concord Hospital and customized it for DFCI (Exhibit A).

When we did, we separated the checklist into categories for each job function involved in the product conversion process: clinical nurse specialist (educator), strategic sourcing and contracts manager, materials control (inventory support)—even supplier. Under each we listed each job responsibility during product conversions. We began with a general section identifying whether a conversion should go to a clinical operations team for further discussion or straight to the “huddle” (Figure 1.3, download PDF to view)—for after the products and standards team decides to convert to a new product, we identify key stakeholders and then call a separate “huddle”: a meeting in which the only topic discussed is the conversion. 

Figure 1.3. The huddle provides vision, unity and clarity. [Download the PDF to view image].
According to the Enviable Workplace (“Three elements for powerful workplace team huddles,” 2012):

An interesting element to American football is the team huddle. This is the point of the game where the team members responsible for the running the play circle up for dispensing information regarding how the series is to play out. It isn’t a time for conversation or discussion, it is about the leader sharing a play that everyone is familiar with, understands, and knows their individual roles. The coach sends in the play, the quarterback reiterates it, the team hears it and prepares to act accordingly, they break (generally with a clap and as a unit), and they go make it happen. The huddle is a key element of the sport that speaks to importance of the team by communicating vision, providing clarity and demonstrating unity.

The huddle model can fit easily into business. Much like in a football huddle, the facilitator—the quarterback, as it were—leads the product conversion huddle. Doing so can take a quarter-hour, a whole hour, or several meetings depending on the complexity of the conversion. What’s more, a huddle should take place only if every key stakeholder attends. If one key stakeholder could not attend or did not show up for the meeting, we rescheduled. During this huddle, we took out the checklist and, line by line, identified which tasks need to be completed during the conversion.

Not everything on a checklist needs to be included in every conversion. We use our checklist as a guide. What’s more, certain steps in a conversion cannot begin until something else has been completed. Accordingly, the strategic sourcing and contracts manager acts as the facilitator of the checklist and the conversion. He or she follows up on the completion dates, making contact with each person who has been assigned a task. The process does not move on unless prerequisite tasks are done.

Leadership
In Schneid (2013), we find the following discussion of facilitation:

Facilitating is all about the process and the progress of any team. Good facilitators encourage the team to reach the project outcome. Being an effective facilitator means you have to be detached while still handling the team. Now you may wonder, what makes a good facilitator? While some may define it as being a leader and getting a team to follow your direction and ideas, it can be a little more than that. Try and think of your role as the facilitator as part of a process that gathers all the forces necessary to accomplish one goal. During this process a good facilitator will structure a project and give it clarity. You must try and remain neutral, yet still find value in each member of your team.

Several of the tasks on the checklists associated with the strategic sourcing and contracts manager role are actually completed during the product evaluation process. These include completing the cost analysis, searching for and identifying any existing contracts that would prevent us from converting to a new product, identifying any applicable GPO contracts, and determining whether our satellite locations will participate in this conversion. During the actual conversion, we double-check each of these tasks before marking it complete. The strategic sourcing and contracts manager is also responsible for completing inventory change forms, facilitating the return of remaining product that has been pulled from shelves, and updating the sharps safety website when applicable.

The materials control manager is responsible, as needed, for creating any new item numbers and updating the inventory database, printing bar codes and managing par locations on the nursing floors, managing existing inventory to ensure that it is used up in both the warehouse and on the nursing floors before distribution of new product, and updating all par forms.

The supplier also is an important part of a successful product conversion. Moreover, because suppliers must be fully engaged in the conversion effort, we must engage them early on. After all, we’ll need to know whether the product to which we are converting is a stocked item. If not, can we meet the distributor’s requirements for stocking it? If it is a special order for the distributor, how long will it take to get it ordered and stocked, then ready for us to order? We also need to know whether the distributor will sell it to us in the unit of measure that we require. Note, too, that if the distributor stocks a product unique to us, we will be required to use remaining stocks of that product before we can change to another product. Accordingly, we make sure to have a stocking agreement in place with the distributor, identifying the maximum amount of product for whose use we can be held responsible before we change to another product.

The final and most important section of the checklist is communication. Nothing is worse than thinking that a conversion went very well but then hearing that a key stakeholder didn’t even know that the conversion would be happening. We discovered this for ourselves during our first conversion. Our nursing directors felt no need to directly communicate with the clinic assistants, for the assistants always received communications from their managers—we thought. But we were wrong, and we found out our error the hard way.
Wikoff (n.d.) summarizes the issue well:

“What we’ve got here is a failure to communicate.” This famous line from the 1967 movie Cool Hand Luke, starring Paul Newman, appropriately depicts the unfortunate fact that most business leaders are ineffective in their communications to stakeholders during transformational improvement initiatives like lean, operational excellence or Reliability Excellence. Communication is paramount when trying to raise the level of understanding in your organization. Many public relations consultants will tell you that the key to communicating is to use multiple platforms or media to communicate the same message. Most will tell you to communicate the same message three to six times, and I don’t disagree. However, I think too much emphasis is put on how to communicate instead of talking about what we should communicate and who should deliver the communications.

Accordingly, we listed all the ways we would communicate a product conversion. What’s more, we met with the nursing directors to understand the ins and outs of how they communicate with their staff. When we did, we learned that each floor had its own unique ways of communicating with its staff—manager and nursing leadership meetings, staff meetings, intranet communications, communication binders on nursing floors, posters or flyers complete with images and posted at nursing stations and in supply closets, even announcements in the par location bins and emails. For our own part, we have purchased small whiteboards and hung them in every supply closet, using them as a two-way communication tool between nursing and supply chain personnel. We often use these whiteboards to communicate a product conversion.

Some conversions will require all these communication methods; others might require no more than a flyer in the supply closet and an email communication. What is essential is that the message reach all members of staff who will be affected by this change.

Case Study 2: Emesis Basins
Our first product conversion after developing our new “huddle” process and our new product conversion checklist came in the form of an opportunity identified by one of our nursing directors. She asked why we had so many plastic kidney-shaped “emesis” basins, then compounded the question by asking whether we knew what they were being used for. After talking with many members of clinical staff, we discovered that they used the basins to carry supplies from the supply closets to the bedside. What’s more, we discovered that we also stocked emesis bags—and that these, not the basins, were what nauseated patients were using. When we presented our findings to the products and standards team, the clinical representative from our Jimmy Fund Clinic noted that one of our affiliate hospitals used cardboard “French fry” containers, suggesting that we try doing the same. Not only would it cost less, but also it would be a “green” initiative.

During the huddle for this product conversion, we used our checklist for the first time. After making sure that each key stakeholder was in possession of his or her own copy of the checklist, we went through it line by line, identifying every step that would need to be completed to accomplish this product conversion. Each key stakeholder left the meeting personally responsible for certain tasks, complete with due date. The facilitator confirmed each task’s completion as the due date arrived. After each task had been completed and the product was on site, we announced the conversion to the members of staff.

Figure 1.4. Current state process map. [Download the PDF to view image].
This time, our product conversion went exceptionally well (Figure 1.4). You’ll notice that storm clouds had been replaced by happy clouds. In fact, from start to finish, we couldn’t identify any mistakes that had been made during this product conversion. Key stakeholders were much more collaborative, and the checklist helped us stay on track.

In particular, because we had investigated the various ways that floors communicated with their staff members, we had been able to communicate the conversion in ways that made everyone aware of the change. We included a picture on the flyers posted in the supply closets, and we included that same flyer in email communication.

Because this was a very simple conversion, we didn’t have to include an overwhelming amount of detail on the flyer. We simply introduced the new product, describing it and noting what product it would replace as well as where it could be found. We also included contact information for the benefit of those who had questions about the conversion.

We decided that the Jimmy Fund Clinic would continue using the emesis basins, because they were useful to children who had nausea. Accordingly, when we pulled the emesis basins from the other nursing floors, we saved them for stocking in the Jimmy Fund Clinic.

Our team members were proud of our team’s accomplishment. They saw that a simple tool for keeping organized could mean the difference between failure and success.

Conclusion
Our team members learned a great deal through this process, and since then we have continued to learn and evolve as a team. Our checklist is a dynamic document that continues to be updated as we learn new ways of improving our process. And we’ve concluded one important thing: The product conversion process must be facilitated. Someone must take the lead, managing it from start to finish. Its chances of success are minimal otherwise. Many organizations are fortunate enough to have a nurse or other professional lead their value analysis program, but DFCI does not have that luxury. In our organization, the supply chain leads the product conversion process, ensuring that all the steps identified in the checklist for a particular conversion are completed as prescribed.

Our shared experience has helped strengthen the relationship between nursing and supply chain personnel. We have a new respect for each other’s roles in each product change decision, and we support each other. We’ve been able to reach this point by relying on certain keys to success, all of which depend on consistent checklist application: identifying key stakeholders, requiring 100 percent attendance at meetings, adequately preparing for and identifying all barriers before making any product change decisions, providing education as needed, and using comprehensive communication strategies. For this to last, understanding all the different ways that your customers communicate is critical.

By developing this product conversion process, we enhanced the effectiveness of our committee and boosted our clinical product excellence while achieving greater levels of cost effectiveness. Through effective change management, we also improved our ways of planning and communicating. The experience has taught us that success comes from collaboration and teamwork. Nursing and supply chain personnel must learn to work together, for all bring unique strengths to the process and to the team. Together, we are strong—and strengthened, we can achieve much.

As I think about how far we’ve come, a quote from Henry Ford according to Conservapedia, says it all:
“Coming together is a beginning. Keeping together is progress. Working together is success,” said Ford. “If everyone is moving forward together, then success takes care of itself.” By taking an intentional approach to change management and collaboration, we have at last found success.

References
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Nathan, D. (2014, April). “The History of Dana-Farber Cancer Institute and the Jimmy Fund” [display]. Dana-Farber Cancer Institute.

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Wikoff, D. (n.d.). “How to communicate effectively within the change process.” Retrieved from http://www.reliableplant.com/Read/23535/communicate-effectively-change-process